Surgical (static, dynamic) and non-surgical treatment options for facial nerve palsy aim to restore function and symmetry. This details the management algorithm
Aims of Facial Palsy Treatment
In patients with a facial nerve palsy or paralysis, the aim of treatment, reconstruction and reanimation is a balance of restoring function, achieving cosmesis and reducing morbidities associated with surgery.
From a surgical perspective, the success of facial nerve surgery can be assessed by:
- Symmetry at rest
- Restore dynamic spontaneous movements
- Ensure competent ocular, nasal and oral sphincters
Strategy for Facial Palsy Treatment
The treatment options for facial nerve palsy can be simplified by looking at two key factors – time and location.
Time is the key determinant for the trophic status of the facial muscles. Evidence suggests that after 18 months of the paralysis, treatment options should recruit new muscle due to:
- Motor End-Plate Atrophy
- Neuromuscular fibrosis
- Muscle atrophy
Facial Nerve Anatomy is discussed in more detail here
In a facial nerve palsy patient, determining the location of the deficit will guide neuronal reconstruction options – particularly if a proximal stump or distal branches are viable. General rules of thumb are:
- Intra-cranial/Intra-temporal: No proximal stump present.
- Extra-cranial: Proximal stump and distal branches present.
Treatment Options for Facial Nerve Palsy
Traditionally, there have been two ways to categorise operative techniques for facial nerve palsy – non-operative (conservative) and operative (static and dynamic).
Another method is to understand what needs restoring – neural control to denervated facial musculatureand/or muscle to create symmetric resting tone and spontaneous dynamic smile.
Non-Operative Treatment of Facial Nerve Palsy
Non-operative treatments are considered in a select group of patients, whom do no want surgery. Treatment is performed in a multidisciplinary manner and may include the following:
- Eye protection with regular eye drops, glasses, taping eyelids closed at night
- Physiotherapy – neuromuscular retraining can be beneficial in partial paralysis
- Botulinum Toxin (Botox) – injection into the non-paralysed side can restore facial symmetry, correct ptosis, treat synkinesis and crocodile tears.
- Filler – asymmetry of the cheeks and nasolabial folds can be improved with fillers
Primary Nerve Repair/Direct Neurorrhaphy
Indication: Acute extra-cranial facial nerve injury, with proximal nerve stump and viable facial muscles, that can be repaired under minimal tension.
Primary nerve repair provides the best chance of nerve function recovery1. It is the treatment of choice for acute extra-cranial facial nerve injuries1 as there is a proximal and distal stump. In terms of the surgical technique:
- Tension-free nerve coaptation with minimal anatomical displacement2 as tension has a negative impact on neuronal sprouting. to reduce neuronal sprouting.
- Within 72-hours to allow identification with a nerve stimulator.
- Epineural vs perinueral is adequate2
- Suture or fibrin glue – with no convincing superiority outcomes currently3
Ipsilateral Nerve Grafting
Indication: Acute extra-cranial nerve injuries, with a proximal stump and viable facial muscles, that cannot be repaired primarily without tension3 4
Autologous ipsilateral nerve grafting is indicated in patients with facial palsy and a wide neural gap. Nerve grafting should go beyond the zone of injury.
Donor nerves for this technique include:
- Greater auricular nerve – 10 cm length, proximity to operative field
- Sural nerve – 35cm length that can be neurolysed as segments5 and allows a two-team approach with minimal donor-site morbidity.
- Antebrachial cutaneous nerves6
- Cervical Plexus – proximity to the operative field.
Disadvantages of this nerve grafting include:
- Numbness at donor site – for example: sural nerve and lateral foot paraesthesia
- Inadequate size match of donor and recipient nerves.
- Associated with synkinesis if performed in the intraosseous part of the facial nerve.
Cross-Facial Nerve Graft
Indication: Facial Palsy with no proximal stump. This may be supplemented with a muscle transfer if no viable facial muscle in injuries in long-standing paralysis.
This technique provides cross-innervation from the non-paralysed contralateral side to the paralysed ipsilateral side. A cross-facial nerve graft is the best method to achieve symmetrical spontaneous motion.
Different options and varations exist with this technique:
- Copatation into the distal nerve stump or directly into the muscle (neurotisation)
- Prior to a free muscle transfer – this two-stage procedure allows motor axons to grow across over a period of 9-12 months.
- In conjunction with a “babysitter procedure” – a temporising measure in which a cranial nerve transfer is used to provide faster re-innervation to preserve the musculature and possibly the denervated stump while the axons grow across the cross-face nerve graft. For example, the motor nerve to masseter.
- Coordinated facial motion – the fibers from the unaffected facial nerve act as ”pacemarkers” for the affected side.
- Prolonged denervation period of the affected facial muscles whilst regeneration and elongation
- of the contralateral axons take place. This could lead to irreversible muscle atrophy.
Indication: Facial Palsy with no proximal stump and intact distal nerves. This may be supplemented with a muscle transfer if no viable facial muscle in injuries.
Nerve transfers are suitable for patients with an intact distal nerve but no proximal stump. In rarer cases, it can also be used in Mobius Syndrome where a cross-facial nerve graft is contra-indicated or as a baby-sitter procedure, as described above.
Donors nerves include: glosspharyngeal, accessroy, phenic and hypoglossal.
- Provide good muscle tone
- Powerful excursion
- Loss of function of donor cranial nerve (unless end-to-side coaptation or using only parts of the donor nerve)
- Movement produces is uncoordinated (sykinesis)
- If hypoglossal nerve used, results in ipsilateral atrophy of tongue musculature, which affects speech and swallowing.
Local Muscle Transfer
Indication: When there is no viable musculature.
When there is no viable musculature, then muscle should be imported. The ideal muscle would be: small, easily divided into multiple independent strips with good excursion, have long neurovascular hilum and leave no functional deficit – this muscle does not exist.
Local muscle flaps have been described to dynamize the face by utilising the functional trigeminal nerve on the paralysed size.
- Temporalis Muscle – described by Gilles, Labbé, Hault
- Masseter Muscle
- Muscle transpositions are usually unable to recreate a spontaneous dynamic smile as activation of the muscle requires a specific maneuver (such as clenching the teeth)
Free Muscle Transfer
Facial re-animation with free muscle transfer is now the standard of care in appropriate patients with facial nerve palsy. Outcomes from free muscle transfers are recognised as providing results superior to cranial nerve transfer or local muscle transposition. This technique involves both neural control and muscle recruitment.
- Match size of donor and recipient nerves
- Leave the donor short to minimize re-innervation time
- Allow for 50% loss of power following transfer
- Match size and shape of donor muscle to available pocket.
Donor Muscle Options:
- Latissimus Dorsi
- Pectoralis Minor
- Extensor digitorum brevis
- Gracilis Muscle
Neural Control Options:
To restore neural control, a choice exists between direct coaptation to facial nerve, cross-face nerve graft (two-stage) or a masseteric nerve transfer (one-stage) to power the muscle transplant or reinnervate the viable facial musculature.
This is indicated when there is no peripheral stump. Direct neurotizations to the muscle target can take place, provides that the period elapse is no more than 2 years and pre-operative EMG yields high fibrillations.
Donor nerves for this operation include:
- Contralateral facial nerve
- Ipsilateral hypoglassal or massteric, C7 root or part of accessary nerve.
Indication: To correct symmetry at rest for patients with long-standing paralysis without viable facial musculature and/or not suitable for complex surgery.
Static procedures generally reserved for patients who have an established paralysis without variable facial muscular and are unfit or refused more complex surgery. They address asymmetry at rest.
Examples of static procedures include:
- Static suspension: facelift, fascia lata sling
- Correction of drooling
- Gold weight into upper lid
- Brow lifts
- 1. Humphrey C, Kriet J. Nerve repair and cable grafting for facial paralysis. Facial Plast Surg. 2008;24(2):170-176. doi:10.1055/s-2008-1075832
- 2. Gordin E, Lee T, Ducic Y, Arnaoutakis D. Facial nerve trauma: evaluation and considerations in management. Craniomaxillofac Trauma Reconstr. 2015;8(1):1-13. doi:10.1055/s-0034-1372522
- 3. Bozorg Grayeli A, Mosnier I, Julien N, Garem H, Bouccara D, Sterkers O. Long-term functional outcome in facial nerve graft by fibrin glue in the temporal bone and cerebellopontine angle. Eur Arch Otorhinolaryngol. September 2004:404-407. doi:10.1007/s00405-004-0829-6
- 4. Millesi H. The nerve gap. Theory and clinical practice. Hand Clin. 1986;2(4):651-663. https://www.ncbi.nlm.nih.gov/pubmed/3539948.
- 5. Chu E, Byrne P. Treatment considerations in facial paralysis. Facial Plast Surg. 2008;24(2):164-169. doi:10.1055/s-2008-1075831
- 6. Myckatyn T, Mackinnon S. The surgical management of facial nerve injury. Clin Plast Surg. 2003;30(2):307-318. doi:10.1016/s0094-1298(02)00102-5
- 7. Darrouzet V, Duclos J, Liguoro D, Truilhe Y, De B, Bebear J. Management of facial paralysis resulting from temporal bone fractures: Our experience in 115 cases. Otolaryngol Head Neck Surg. 2001;125(1):77-84. doi:10.1067/mhn.2001.116182
- 8. Liu Y, Han J, Zhou X, et al. Surgical management of facial paralysis resulting from temporal bone fractures. Acta Otolaryngol. 2014;134(6):656-660. doi:10.3109/00016489.2014.892214
- 9. Nash J, Friedland D, Boorsma K, Rhee J. Management and outcomes of facial paralysis from intratemporal blunt trauma: a systematic review. Laryngoscope. 2010;120 Suppl 4:S214. doi:10.1002/lary.21681